Abdominal Pain in Children with Choledochal Cyst

Islam, ISSA

Department of Medicine, Oriana Hospitals and Clinics, Sharjah, UAE

*Correspondence to: Dr. Islam, ISSA, Internal Medicine Specialist, Diploma in Tropical Medicine, Oriana Hospitals and Clinic, Sharjah, UAE.

Copyright © 2023 Dr. Islam, ISSA, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abbreviations
ALT alanine amino transferase,
AST aspartate amino transferase,
GGT gamma glutamyl transferase,
Alk pho alkaline phosphatase,
MRCP magnetic resonance cholangiopancreatography

Case Report
8 year old female patient presented to our hospital for the first time 12-26-2022, with her mother, complaining of recurrent episodes of abdominal pain and vomiting for few months, which had been persistent for the last 4 days before presentation, associated with dark urine, and vomited once in the hospital.

On examination: she looked average in stature, calm, communicating and dose not look in acute distress, however looked tired.

Abdomen was bloated with mild epigastric and right upper quadrant pain without rebound tenderness or rigidity.

She denied: a relationship between the pain episodes and specific food, presence of diarrhea, fever, weight loss or growth reduction.

Examination of other systems were within normal.

Laboratory result: ALT : 266 u/l ( 0-55), AST 253 u/l ( 0-34), GGT = 386 u/l( 5-36 ), alkaline phosphatase = 271 u/l ( < 500 ), amylase = 18 u/l ( 8-51), lipase = 151.83 u/l ( <60 ), bilirubin direct = 0.2 mg / dl ( 0-0.5 ), bilirubin indirect = 0 mg/l ( 0.3-0.7), prothrombin time = 10.6 ( 11.1-14.3), hepatitis A antibodies IgM and IgG = negative, tissue transglutaminase IgA antibodies = negative, anti nuclear antiboidies ANA = negative, ebstien bar virus antibodies = negative, TSH thyroid stimulating hormone = 0.57 uiu (0.7-6.4), FT4 free thyroxine 4 = 14.4 pmol/l ( 9.01-19.05), FT3 free thyroxin 3 = 4.6 pmol/l ( 1.58-4.6). WBCs white blood cells, hemoglobin and platelet = within normal, CRP C-reactive protein = 10.7 mg/l (<5), urine showed ketones 2+, normal sodium and potassium.

Ultrasound Abdomen
• The liver is of normal in size (measuring 110mm) displaying coarse hepatic echotexture and no focal lesions seen.
• Evidence of fusiform cystic dilation of entire extrahepatic bile duct (10 mm width) seen posterior medial to the gall bladder with prominent intrahepatic billiary trees, communication with cystic duct cannot be clearly made out (choledochal cyst).
• The gall bladder is markedly distended.
• The P.V. of normal caliber 8 mm
• The spleen is of normal size measuring 8cm displaying normal echogenicity.
• The pancreatic and para-aortic areas are sonographically free.
• Both kidneys are of normal shape and size appearing well-differentiated with no calculi or back-pressure changes detected.
• The urinary bladder is well-distended displaying normal lumen and wall thickness. No stones, masses detected.
• No ascites.

According to ultrasound results, patient was sent to pediatric hospital - Jalilah - in Dubai for further investigation (MRCP) and MRCP was done and revealed:

Common bile duct is prominent measuring 9mm at the porta with normal distal tapering.

Mild prominence of the right and left hepatic duct (left

Pancreas appears bulky especially the body and tail region with prominent pancreatic duct in the ail region.

No definite mass lesion seen. No scculations or outpouching of the pancreatic duct noted.

Case was diagnosed as choledochal cyst type 1 and surgeon took care of the case.

Results and Discussion
Laboratory results showed abnormal liver enzymes ALK phos is normal with elevated GGT and elevated lipase denoting hepatic-pancreatic involvement, supported by ultrasound finding of dilatation of extrahepatic duct and MRCP.

While abdominal pain in kids is a common complaint and in most of the time nothing would be done more than appropriate diet or symptomatic treatment. However, detailed history and thorough physical examination with appropriate apprehension and judgment would lead physician to the necessary investigations [1-5].

Conflict of Interest
I have no financial interest or any conflict of interest exists.

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